2025 CPT code 52315
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Surgery - Surgical Procedures on the Urinary System Surgery Feed
Complicated cystourethroscopy with removal of foreign body, calculus, or ureteral stent.
Modifiers 22 (Increased Procedural Services), 51 (Multiple Procedures), 59 (Distinct Procedural Service), and others may be applicable depending on the circumstances of the procedure.
Medical necessity is established when the presence of a foreign body, calculus, or displaced ureteral stent in the bladder or urethra causes symptoms or complications that require removal.Documentation should clearly show the presence of the object and the justification for its removal via cystourethroscopy.
The urologist or surgeon is responsible for performing the procedure, including pre-operative preparation, insertion and manipulation of the cystoscope, removal of the foreign body/calculus/stent, post-operative care, and addressing any complications that may arise.
In simple words: The doctor uses a thin, lighted tube to examine the bladder and urethra. If there's a stone, foreign object, or a displaced stent, the doctor removes it using small instruments passed through the tube. The procedure might take longer if there are complications like bleeding or tears.
This procedure involves a complicated cystourethroscopy, including inspection of the bladder, urethra, prostatic urethra, and ureteric openings using a cystoscope.A foreign body, calculus (stone), or displaced ureteral stent is removed through the cystoscope.Additional time may be needed due to complications such as excessive bleeding, inadvertent ureteral tear, stricture, or other unforeseen circumstances.
Example 1: A patient presents with a ureteral stent that has migrated into the bladder.The urologist performs a complicated cystourethroscopy to remove the stent, encountering significant bleeding during the procedure, requiring additional time for hemostasis., A patient presents with a large bladder stone causing urinary obstruction. The urologist performs a cystourethroscopy to remove the stone; however, the stone is difficult to remove due to its size and location, and there is an inadvertent tear in the bladder wall which requires repair. This is reported as 52315., A patient presents with a foreign body (a small piece of metal) lodged in the urethra that cannot be easily removed.The urologist performs a complicated cystourethroscopy to remove the foreign body using specialized grasping forceps. Extra time is required because of the difficulty accessing and removing the foreign body due to location and size. The procedure is reported with 52315.
* Detailed operative report including the type of foreign body/calculus/stent removed.* Description of any complications encountered (bleeding, tears, strictures).* Time spent performing the procedure.* Imaging studies (if any) to locate the foreign body/calculus/stent.* Pre-operative and post-operative diagnoses.* Patient's response to the procedure.
** This code is used for complicated cystourethroscopies.Simple procedures should be coded using 52310.Always refer to the most current CPT coding guidelines and payer-specific requirements for accurate billing.
- Revenue Code: P8E (ENDOSCOPY - CYSTOSCOPY)
- RVU: This information is not available in the provided text.Refer to the CMS (Centers for Medicare & Medicaid Services) website or other relevant resources for the most up-to-date RVU values.
- Global Days: The global period for this procedure is not specified in the provided text.This will depend on payer-specific guidelines and the complexity of the procedure.
- Payment Status: Active
- Modifier TC rule: Not applicable for this code.
- Fee Schedule: This information is not available in the provided text.Refer to historical fee schedules from CMS or other relevant sources.
- Specialties:Urology
- Place of Service:Office, Ambulatory Surgical Center, Hospital (Inpatient or Outpatient)